I recommend using Nitrous Oxide during treatment of your child; Nitrous Oxide is breathed through a nasal mask, and after a state of relaxation is reached, local anesthesia ("Novocaine" or "the shot") will be administered if required for the procedure.

Please read each bullet point below, ask any related questions, and initial that you understand.

I understand that Nitrous Oxide will only provide relaxation and that local anesthesia may still be necessary.

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I understand that Nitrous Oxide is not a ‘cure-all’ and may not be compatible with my child’s needs and that absolute success can not be guaranteed.

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I understand that the administration of nitrous oxide carries with it certain risks and potential unpleasant side effects.These include, but are not limited to shivering, nausea and vomiting, or a 'light headed' feeling.

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I accept and understand that the alternatives to Nitrous Oxide administration are:

No Nitrous Oxide. The necessary procedure is performed and local anesthetic ("novocaine") is used as needed.

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General Anesthesia which requires that the patient to be treated at a hospital.

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I have been informed of the benefits, risks and alternatives regarding the administration of Nitrous Oxide to my child.

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I am aware that the per-visit fee of $60 for Nitrous Oxide is non-refundable regardless of the visit outcome.

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I am aware that I may NOT take videos or photographs of my child during treatment.

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I am aware that the failed appointment fee for a Nitrous Oxide appointment is $80.

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I am aware of the 48-hour cancellation policy for Nitrous Oxide appointments.Cancellation must be made 2 business days prior to appointment to avoid $80 fee.

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I consent and authorize Dr. Capalbo to use Nitrous Oxide (laughing gas) during the treatment of my child.

I certify that the information provided in this form is correct to the best of my knowledge.
I also certify that I am the person who I claim to be and I am not falsely representing another individual.

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